Fellow: Melanie Rudnick, Children's Hospital Los Angeles, University of Southern California, Keck School of MedicineArticle: Tagarro A et al, "Dexamethasone for Parapneumonic Pleural Effusion: A Randomized Double-Blind, Clinical Trial" J Pediatr 2017;185:117-23​Summary: The authors compared the use of dexamethasone plus antibiotics to antibiotics alone in 60 pediatric patients presenting with pneumonia with parapneumonic effusion in 9 centers in Spain over a 5 year period. Their primary outcome measure was time to recovery defined as temperature <37C, SpO2 >92%, no respiratory distress, end of invasive procedures, pneumonia resolving on imaging, and presence of oral feeding. Overall, median time to recovery in patients receiving dexamethasone in addition to standard therapy was significantly reduced (109 vs 177 hours) compared to standard therapy alone. When stratified based on simple vs complicated effusion, there was a statistically significant difference in the simple effusion group (n=36, 48 vs 133 hours, p=0.017), but not with those with complicated pneumonia (n=24, 226 vs 240 hours, p=0.66). Rates for a chest drainage procedure were not different between groups and hyperglycemia was the only adverse event that occurred more often in the dexamethasone group.What are the key strengths of the article?This is a prospective, randomized, multi-center double-blind placebo-controlled trial, with appropriate statistical analysis. They accurately accounted for missing data, and were explicit in describing the results of analyses and whether or not they were powered for these.

Are there any limitations or flaws in the article?Limitations include the small sample size and the long duration of enrollment (5 years) during which standard care practice may have changed. The primary outcome (“time to recovery”) is specific to this study and may not be reproducible in other settings and decrease external validity. Perhaps a better outcome would have been length of stay, which is easy to compare across hospitals. Although the study reports differences between subgroups (simple vs. complicated) and need for pleural drainage, it was not adequately powered for these outcomes. The definition of simple and complex effusion was based on size (10mm) instead of more clinically significant criteria (proportion of the pleural cavity), which may lead to misclassification bias.

What is the major takeaway message?Adding dexamethasone to standard antibiotic treatment may improve time to recovery in patients presenting with pneumonia and simple parapneumonic effusions. Further study in larger populations should investigate other outcomes (i.e. length of stay, readmissions, longer-term pulmonary outcomes), safety, and dosing.

Describe how this article should impact our practice:Due to the limitations discussed above, this article should not immediately change standard of care. However, the findings are promising and should lead to additional research about adjunctive corticosteroid use in this common clinical pediatric condition that often requires hospitalization.